Degenerative Cervical Myelopathy: Recognition and Management

 

Am Fam Physician. 2020 Dec 15;102(12):740-750.

  Patient information: See related handout on degenerative cervical myelopathy

Author disclosure: No relevant financial affiliations.

Degenerative cervical myelopathy encompasses a collection of pathologic conditions that result in progressive spinal cord dysfunction secondary to cord compression. Patients are typically male (3:1 male-to-female ratio), and the average age of presentation is 64 years. The exact incidence is unclear because of differences in terminology and because radiographic findings can be present in asymptomatic individuals. Common examination findings include neck pain or stiffness, a wide-based ataxic gait, ascending paresthesia in the upper or lower extremities, lower extremity weakness, decreased hand dexterity, hyperreflexia, clonus, Babinski sign, and bowel or bladder dysfunction in severe disease. Definitive diagnosis requires correlation of physical examination findings with imaging findings. Magnetic resonance imaging of the cervical spine with and without contrast media is the preferred imaging modality. Cervical spine computed tomography, computed tomography myelography, and plain radiography are helpful in certain situations. Treatment depends on the presence and severity of symptoms. Surgery is recommended for patients with moderate to severe symptoms or rapidly progressive disease. Conservative treatments with monitoring for progression may be considered in patients with mild to moderate disease. The evidence for the effectiveness of conservative treatments is scarce and of low quality, and outcomes can vary with individual patients. Primary care physicians play a vital role in recognizing the typical presentation of degenerative cervical myelopathy, coordinating treatment as indicated, and managing comorbidities.

Degenerative deterioration of the vertebrae, intervertebral disks, the facet, and other joints of the spine can result in cervical spondylotic myelopathy.1,2 Hypertrophy and ossification of the posterior longitudinal ligament and the ligamentum flavum can lead to spinal cord compression, injury, and subsequent myelopathy.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Conservative treatment is an appropriate initial option for patients with mild to moderate symptoms.5,36,37

B

Randomized controlled trial and systematic review 20% to 60% of these patients will deteriorate over three to six years and may eventually require surgery7,10,11

Since a delay in the diagnosis of degenerative cervical myelopathy can lead to poorer outcomes, evaluation and referral should be done in a timely manner. The symptoms of degenerative cervical myelopathy are persistent, with upper motor neuron signs and symptoms as the hallmark of the condition.2,12

C

Practice guidelines and expert opinion

Magnetic resonance imaging is the imaging modality of choice for patients with suspected degenerative cervical myelopathy.34

C

Consensus practice guidelines

Surgical management is indicated for patients with moderate to severe myelopathic signs and symptoms; however, even with surgery, many patients have residual deficits.9,28

C

Practice guidelines and expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Conservative treatment is an appropriate initial option for patients with mild to moderate symptoms.5,36,37

B

Randomized controlled trial and systematic review 20% to 60% of these patients will deteriorate over three to six years and may eventually require surgery7,10,11

Since a delay in the diagnosis of degenerative cervical myelopathy can lead to poorer outcomes, evaluation and referral should be done in a timely manner. The symptoms of degenerative cervical myelopathy are persistent, with upper motor neuron signs and symptoms as the hallmark of the condition.2,12

C

Practice guidelines and expert opinion

Magnetic resonance imaging is the imaging modality of choice for patients with suspected degenerative cervical myelopathy.34

C

Consensus practice guidelines

Surgical management is indicated for patients with moderate to severe myelopathic signs and symptoms; however, even with surgery, many patients have residual deficits.9,28

C

Practice guidelines and expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

This article focuses on the progressive and degenerative musculoskeletal changes that lead to pathologic changes in the spinal cord. Many other conditions can lead to myelopathy (Table 14) and should be considered

The Authors

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SHAWN F. KANE, MD, FAAFP, FACSM, is an associate professor in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine....

KATARINA V. ABADIE, MD, is a resident in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine.

ADAM WILLSON, MD, is a resident in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine.

Address correspondence to Shawn F. Kane, MD, FAAFP, FACSM, University of North Carolina at Chapel Hill, 590 Manning Dr., Chapel Hill, NC, 27599 (email: shkane@email.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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